CCSP CCSPathw thways ys HUB HUB CHW CHW Leading the Way in Delivering Better Community Health 1
Reducing Risk f ducing Risk for Communities r Communities 2
CCSP CCSPathw thways ys Pathways – Evidence‐based model for risk reduction integrated with community‐ based care coordination. Pathways HUB – Community‐based, neutral entity that convenes and facilitates community care coordination. Pathways HUB Connect and Mobile – Tools to enable care coordination, connectivity and reporting. Professional Development – Activation of care coordinators and HUB staff. Pathways Risk Q – Evaluates population risks. Actionable results for care teams. Certified Pathways HUBs – Optimization, Comparability, Best Practices, Quality Assurance 3
Care Coordination Systems CCS pr CCS provides the P ides the Path athways ys Community HUB solution - Community HUB solution - includin ncluding Certified Pathways HUB the necessary com the necessar y comprehensiv rehensive e ser services and syst ices and systems - ems - that can lead hat can lead to HUB cer HUB certification. ification. Pathways RiskQ – Pathways Pathways HUB Connect & – Training Pathways Community – Pathways mobile and HIPAA software CHW & Pathways – Integrated patient portal CHW CHW Training – Customizable systems – HUB operations advisory – Risk Scoring and stratification Pathways Leading the Way in Delivering Better Community Heath 4
Dramatic Pathways Results 18 Maternal and Child Health Journal 16 Achieved 14 13.0 through focus % of Low Birth Weight Births on social risk 12 factors and organized care 10 coordination 8 in Pathways 6.1 Community 6 HUB 4 2 0 Maternal and Child Health Journal ISSN 1092-7875 Control Pathways Matern Child Health J Group Intervention DOI 10.1007/s10995-014-1554-4 Leading the Way in Delivering Better Community Heath
Lucas County African American Percentage of NW Ohio Pathways Clients Low Birth Weight Rates Attending Post-Partum Appointment 16 2012-2014 13.4 13.2 80 80% 14 74% 79% 12 70 9.5 9.5 10 60 8 50 6 40 4 30 2 20 0 10 Ohio 2013 Lucas Pathways Pathways 2012 2013 2014 County 2013 2014 In 2013, 63% of women on 2013 Medicaid attended post-partum appointment within 90 days
Medicaid Costs: P ER M EMBER P ER M ONTH $1,600 $1,600 Cohort 1 $1,200 $1,200 Cohort 2 $800 $800 Ref: Super- utilizers $400 $400 Ref: Multiple chronic $0 $0 disease B4 B4 B3 B3 B2 B2 B1 B1 T1 T1 T2 T2 T3 T3 B4-B1: 6 month periods before the beginning of MPBH (Jan 2011 – Dec 2012) T1-T3: 6 month periods since MPBH services began (Jan 2013 – June 2014) : indicates cohort enrollment into MPBH
Distinctions between Pathways & HUB Pat Pathways Community HUB Community HUB Care coor Tr Care coordination f dination facilitation t cilitation tool ool Tracks P Pathways ( (outcomes) acr across agencies ss agencies Pa Patient-cent t-centered ered Eliminat Eliminate duplication e duplication Identify patient risks Identify patient risks Streamline ref Streamline referrals rrals Social and traditional health Social and traditional health Pr issues issues identified identified Provide infrastructure f ide infrastructure for r community community-base based care d care Actionable & tionable & accountable accountable coor coordination dination Measured outcomes Measured outcomes In Involv lve braided funding – e braided funding – Trained & q ained & quality assurance t ality assurance to Pathw thways can be pur ys can be purchase hased b d by achieve results achie e results different f erent funder ers Pa Payments f yments for measured Pathw r measured Pathway y In Invoicing syst icing system em outcom outcomes 8
Clinics HHS Medicare/ FQHCs Housing Medicaid State Agencies Private Health Plans Hospitals AAA Managed Care County Departments Foundations Physicians HUB One Care Coordinator for the Entire Family 19
CCSP CCSPathw thways Syst ys System em Care Coordination Systems (CCS) system and security highlights: Virtual Private Cloud-based US based-solely. SOC1 and SOC2 environment. NIST cybersecurity standards. Encrypted - volumes (at rest) and in-transit. Redundant encrypted backups geographically. Security compliance Third party independent annual audit Report available as requested 10
CCSP CCSPathw thways T ys Technology chnology – Systems Pathways HUB Connect tm – Pathways Mobile tm – – Services Pathways Risk Q tm – Pathways Insight tm business intelligence – Pathways Community tm HUB integrated education portal – – EMR, HIE, 211 and other connectivity to systems/organizations – Invoicing for outcomes – Direct Messaging & Secure Fax / Care Team status updates – Licensed Screening Tools – PCMH TCM/CCM Tools and Reports (new) – Healthy Start Tools and Reports (new) – Health Homes (in discovery) 11
Pathw thways Mobile ys Mobile Real time Social Determinants 12
Seeing Clearly Seeing Clearly 13
Reporting Re Reports: • Operational • Managerial • Analytical • Specialized / User customized Maps: • Maps through api • Geo-coding of any Pathways or data attribute Dashboards: • Decision and analytical Tableau dashboards • 14
Measure Step 3: T ep 3: Track and Measure Pr ack and Measure Progress with P ogress with Pathw athways ys Example T Exam ple Tracking Filt acking Filters ers • Pr Program ogram • Pa Patient • Health Healthcare Pr care Provide ider • Comm Community unity • Re Region • HUB HUB • Ag Agency • Medical R Medical Referrals rrals • Social Ser Social Service R ice Referrals rrals 15
Pathw thways Risk s RiskQ tm tm Health Behavioral Health Social Patient Activation Family & Personal Health Management Financial
Pathw thways Risk s RiskQ tm tm Reduces Community Risk duces Community Risk Identify and prioritize highest at-risk. Converges real-time Social Determinants of Health information with clinical, financial and geographic information for risk stratification. Risk-adjusted caseloads and metrics for operating performance. Risk-adjusted performance payments for Pathways outcomes achieved. Risk RiskQ charting visually demonstrates risk reduction/levels over time. Risk RiskQ mapping provides geographic visuals of information and scoring. Pathw athways ys Risk RiskQ tm Find and Treat the highest at-risk
Pathw thways Risk s RiskQ tm tm RiskQ status RiskQ status updated daily updat d daily En Envir vironm nmen ental risk b risk by census census tract trac 18
Connectivity and Communication Connectivity and Communication Care Team Dashboard Provider Pathways Direct Messaging Clinic HUB Hospital Virtual Private Network (VPN) Completing the Care Team Loop Health Information Exchange Patient Community Care Team Agency API library Community Care Coordinator • Bi-directional Documented • 19
Connectivity Me Connectivity Methods thods CCS shares information with others via – CSV files extracted from reports and transmitted to secure FTP locations Direct messaging – CCS as its owns HISP (post office) transmits “single” client information to EMR systems, providers, pharmacies, and anyone with a valid HISP/Direct message account. CCS may create a Direct message account(s) as required for external organizations Secure Fax – point to point encrypted fax of client documents Application Program Interface (API) – library of 70+ APIs for connection to organizations and other systems, 20
Connectivity Me Connectivity Methods thods Care Coordination Systems (CCS) shares information with others via – Application Program Interface (API) – – For connectivity with systems and organizations – Library of proprietary 70+ fully documented APIs – APIs are customizable and support bi-directional transfer of information – Currently used to – Health Information Exchange (HIE) via VPN – 211 Referral system – Major national hospital system – Pathways Community – HUB integrated patient/client facing health decision portal – Communications with external vendors – Patient Activation Measure – ASQ Developmental Screening 21
Standard Billing Codes Normal High Modifier Risk Risk Checklists Initial Pregnancy Completed one time at Member enrollment, 1 st G9001 G9003 R1 Checklist trimester engagement Completed one time at Member enrollment, 2 nd G9001 G9003 R2 trimester engagement Completed one time at Member enrollment, 3 rd G9001 G9003 R3 trimester engagement Pregnancy Completed at each face-to-face encounter with G9005 G9010 R Checklist Member Pathways Behavioral Health Kept three scheduled behavioral health appointments G9002 G9009 RB Education Educational module delivered. G9002 G9009 RE Family Planning LARC (long-acting, reversible) or permanent method G9002 G9009 G1 Family Planning All other family planning methods G9002 G9009 G2 Housing Residing in affordable & suitable housing for 2 G9002 G9009 RI months. 22
PREGNANT CLIENT Leading the Way in Delivering Better Community Health 708-906-3057 75 East Market Street Akron, Ohio 44308 Bob.Harnach@ccspathways.com Carecoordinationsystems.com 23 23
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